Adherence to antidiabetic treatment and impaired hypoglycemia awareness in type 2 diabetes mellitus assessed in Spanish community pharmacies: the ADHIFAC study

[Validation of the JH-SEFAC Questionnaire on Knowledge on Insulin Management by Patients with Diabetes in Community Pharmacies]

Objective

To review and validate a questionnaire on knowledge of injectable insulin management (JH-SEFAC) by patients with diabetes for use in community pharmacies.

Methods

Study design: cross-sectional observational in Spanish community pharmacies during the first half of 2023. Inclusion criteria: patients with diabetes, of legal age, on insulin treatment. Questionnaire design: a nominal group of community pharmacists reviewed and piloted the initial questionnaire to determine its feasibility. It was approved by the CEIC of Aragón (PI22/375). Content validation: by a multidisciplinary group of experts in diabetes, using an ad hoc evaluation questionnaire of 10 questions (Likert scale of 1-5). Reliability: by means of the internal consistency index (Cronbach's alpha) and the intraclass correlation coefficient (ICC). Reproducibility (test/retest): the results of the questionnaire administered twice 2-3 weeks apart to the group of patients were compared. Pharmacists members of the SEFAC Diabetes Working Group collaborated. Sample: calculated in 127 subjects (95% CI and precision of 10%).

Results

20 community pharmacies from 13 autonomous communities included 131 patients. The expert assessment was 4.52 out of 5 (90.4%). The Keiser-Meyer-Olkin test was 0.626 and Bartlett's test was significant (p<0.001). The Cronbach's alpha of the global questionnaire was 0.804 and the ICC was 0.902. The mean score of the questionnaire was 15.98 out of 31 points.

Conclusions

The JH-SEFAC questionnaire was validated to evaluate the management of insulin injectables, providing community pharmacists with a valuable tool for therapeutic education.

Long-Term Sulfonylurea Use and Impaired Awareness of Hypoglycemia Among Patients With Type 2 Diabetes in Taiwan

PURPOSE

We undertook a study to investigate the relationship between duration of medication use and prevalence of impaired awareness of hypoglycemia (IAH) among patients with insulin-treated or sulfonylurea-treated type 2 diabetes in Taiwan.

METHODS

A total of 898 patients (41.0% insulin users, 65.1% sulfonylurea users; mean [SD] age = 59.9 [12.3] years, 50.7% female) were enrolled in pharmacies, clinics, and health bureaus of Tainan City, Taiwan. Presence of IAH was determined with Chinese versions of the Gold questionnaire (Gold-TW) and Clarke questionnaire (Clarke-TW). Sociodemographics, disease and treatment histories, diabetes-related medical care, and health status were collected. We used multiple logistic regression models to assess the relationship between duration of medication use and IAH.

RESULTS

Overall IAH prevalence was 41.0% (Gold-TW) and 28.2% (Clarke-TW) among insulin users, and 65.3% (Gold-TW) and 51.3% (Clarke-TW) among sulfonylurea users. Prevalence increased with the duration of sulfonylurea use, whereas it decreased with the duration of insulin use. After controlling for potential confounders, 5 or more years of sulfonylurea use was significantly associated with 3.50-fold (95% CI, 2.39-5.13) and 3.06-fold (95% CI, 2.11-4.44) increases in the odds of IAH based on the Gold-TW and Clarke-TW criteria, respectively. On the other hand, regular blood glucose testing and retinal examinations were associated with reduced odds in both insulin users and sulfonylurea users.

CONCLUSIONS

The prevalence of IAH was high among patients using sulfonylureas long term, but the odds of this complication were attenuated for those who received regular diabetes-related medical care. Our study suggests that long-term sulfonylurea use and irregular follow-up increase risk for IAH. Further prospective studies are needed to confirm the observed associations.Annals Early Access article.

Non-adherence to non-insulin glucose-lowering drugs: Prevalence, predictors and impact on glycemic control and insulin initiation. A longitudinal cohort study in a large primary care database in Spain

BACKGROUND

A better understanding of patient non-adherence to type 2 diabetes medication is needed to design effective interventions to address this issue.

OBJECTIVES

(1) To estimate the prevalence of non-adherence to diabetes medication; (2) to examine its impact on glycemic control and insulin initiation; (3) to develop and validate a prediction model of non-adherence.

METHODS

We conducted a longitudinal cohort study based on data from electronic health records. We included adult patients registered within the Health Service of the Balearic Islands (Spain) starting a new prescription of a non-insulin glucose-lowering drug between January 2016 and December 2018. We calculated non-adherence at 12 months follow-up, defined as medication possession ratio (MPR) ≤ 80%. We fitted multivariable regression models to examine the association between non-adherence and glycemic control and insulin initiation and identified predictors of non-adherence.

RESULTS

Of 18,119 patients identified, after 12 months follow-up, 5,740 (31.68%) were non-adherent. Compared with non-adherent, adherent patients presented lower HbA1c levels (mean difference = -0.32%; 95%CI = -0.38%; -0.27%) and were less likely to initiate insulin (aOR = 0.77; 95%CI = 0.63; 0.94). A predictive model explained 22.3% of the variation and presented a satisfactory performance (AUC = 0.721; Brier score = 0.177). The most important predictors of non-adherence were: non-Spanish nationality, currently working, low adherence to previous drugs, taking biguanides, smoker and absence of hypertension.

CONCLUSION

Around one-third of the patients do not adhere to their non-insulin glucose-lowering drugs. More research is needed to optimise the performance of the predicting model before considering its implementation in routine clinical practice.

A global systematic overview of socioeconomic factors associated with antidiabetic medication adherence in individuals with type 2 diabetes

BACKGROUND

Antidiabetic medication adherence is a key aspect for successful control of type 2 diabetes mellitus (T2DM). This systematic review aims to provide an overview of the associations between socioeconomic factors and antidiabetic medication adherence in individuals with T2DM.

METHODS

A study protocol was established using the PRISMA checklist. A primary literature search was conducted during March 2022, searching PubMed, Embase, Web of Science, as well as WorldCat and the Bielefeld Academic Search Engine. Studies were included if published between 1990 and 2022 and included individuals with T2DM. During primary screening, one reviewer screened titles and abstracts for eligibility, while in the secondary screening, two reviewers worked independently to extract the relevant data from the full-text articles.

RESULTS

A total of 15,128 studies were found in the primary search, and 102 were finally included in the review. Most studies found were cross-sectional (72) and many investigated multiple socioeconomic factors. Four subcategories of socioeconomic factors were identified: economic (70), social (74), ethnical/racial (19) and geographical (18). The majority of studies found an association with antidiabetic medication adherence for two specific factors, namely individuals' insurance status (10) and ethnicity or race (18). Other important factors were income and education.

CONCLUSIONS

A large heterogeneity between studies was observed, with many studies relying on subjective data from interviewed individuals with a potential for recall bias. Several socioeconomic groups influencing medication adherence were identified, suggesting potential areas of intervention for the improvement of diabetes treatment adherence and individuals' long-term well-being.

Prevalence and contributing factors of impaired awareness of hypoglycemia in patients with type 2 diabetes: a meta-analysis

AIMS

To conduct a systematic review to summarize the definition, measurement tools, prevalence, and contributing factors of impaired awareness of hypoglycemia (IAH) in type 2 diabetes mellitus (T2DM).

METHODS

A reproducible search strategy was used to identify factors affecting IAH in T2DM in PubMed, MEDLINE, EMBASE, Cochrane, PsycINFO, and CINAHL from inception until 2022. Literature screening, quality evaluation, and information extraction were performed independently by 2 investigators. A meta-analysis of prevalence was performed using Stata 17.0.

RESULTS

The pooled prevalence of IAH in patients with T2DM was 22% (95%CI:14-29%). Measurement tools included the Gold score, Clarke's questionnaire, and the Pedersen-Bjergaard scale. IAH in T2DM was associated with sociodemographic factors (age, BMI, ethnicity, marital status, education level, and type of pharmacy patients visited), clinical disease factors (disease duration, HbAlc, complications, insulin therapy regimen, sulfonylureas use, and the frequency and severity of hypoglycemia), and behavior and lifestyle (smoking and medication adherence).

CONCLUSION

The study found a high prevalence of IAH in T2DM, with an increased risk of severe hypoglycemia, suggesting that medical workers should take targeted measures to address sociodemographic factors, clinical disease, and behavior and lifestyle to reduce IAH in T2DM and thus reduce hypoglycemia in patients.

Adherence to antidiabetic treatment in primary health care in individuals with type 2 diabetes. A survey including socio-demographic, patient related and clinical factors

BACKGROUND

Adherence to medications is a critical element in diabetes management.

OBJECTIVE

To investigate patient-related factors associated with adherence to antidiabetic treatment in patients with type 2 diabetes in primary health-care units.

METHODS

A cross-sectional study among patients receiving diabetes care in 18 primary care units in Mexico City was conducted. Data were collected from medical records and medical interviews. Adherence to antidiabetic therapy and patient-related factors associated with adherence were evaluated through a self-administered questionnaire. Socio-demographic, clinical, behavioral (self-care activities including a healthy diet, exercise or physical activity, self-monitoring of blood glucose testing, and foot care), and patients-adherence-related factors (health-care provider-patient communication; daily and social activities, and support network; alternative treatment beliefs; comorbidity, diabetes symptoms, and treatment; side effects and treatment access) were compared between the adherent and non-adherent group.

RESULTS

Of 319 outpatients, 48.3% were adherent to their antidiabetic therapy. In the adjusted analysis, patient-related factors associated to adherence were exercise and physical activity self-care behavior (OR=1.26; 95%CI 1.09-1.46), treatment interference with daily activities (OR=0.27; 95%CI 0.14-0.52), not satisfied with resolution of questions by the physician (OR=0.42; 95%CI 0.19-0.94), independently to increased cardiovascular risk and insulin treatment.

CONCLUSION

A low proportion of outpatients with T2D with regular primary care were adherent to diabetes treatment and this was associated with patient-related factors like answering patients' treatment-related questions by the physician. This information may be useful to identify patients at risk for low adherence, and to guide the design of quality-of-care strategies, like diabetes education programs to address suboptimal adherence in patients, and health-care professional communication skills training, particularly in primary care health systems.

Common Sense Model program on illness perceptions in patients with impaired awareness of hypoglycemia

BACKGROUND

Illness perceptions are important for patients with insulin-treated type 2 diabetes mellitus (T2DM) and impaired awareness of hypoglycemia (IAH), as they determine health-related behaviors and motivations. Patients with IAH in many countries have poor illness perception, and there is a paucity of research exploring the effectiveness of Common Sense Model (CSM)-based interventions in this population.

OBJECTIVE

To investigate the effects of a CSM-based intervention program on perceptions of illness in patients with insulin-treated T2DM and IAH.

DESIGN

Quasi-randomized controlled trialMethods: 78 patients with IAH receiving routine care were included. The intervention group (n = 39) participated in a CSM-based program, whereas the control group (n = 39) did not. Illness perceptions, coping styles, hypoglycemia fear, and awareness of hypoglycemia at baseline, 1 month, and 3 months were analyzed and compared between the two groups.

RESULTS

The intervention group exhibited significant improvements in consequences (β = -1.615, P = 0.032); personal control (β = -1.897, P = 0.006); treatment control (β = -1.274, P = 0.046); and positive coping style (β = 4.872, P = 0.002) at the 3-month follow-up, and timeline (β = 2.769, P = 0.004) at the 1-month follow-up. Hypoglycemia fear and awareness were not significantly improved in the intervention group compared with the control group. No intervention-related adverse events were observed.

CONCLUSIONS

A CSM-based intervention program can modify illness perceptions to an extent and improve the positive coping style in patients with IAH.Impact statement: Nurses should conduct a CSM-based intervention program to help patients with IAH improve illness perceptions.